Download Morning Report 1-25-2017

Management of Acute
Upper GI Bleed
Kirollos Zaki
PGY-1
1/25/2017
Epidemiology & Clinical Presentation
• Annual incidence of hospitalization is 100 per 100,000
• Much more common than lower GI bleed
• Incidence is higher in men than in women
• 128 versus 65 per 100,000 in one study and increases with age
• Presentation:
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Melena
Hematemesis
Hematochezia in small subset of bleeds
PUD: epigastric pain
Ulcers: odynophagia, dysphagia, GERD
Mallory-Weiss: Emesis, retching,
Variceal/Portal HTN: weakness, fatigue, ascites, jaundice
Causes of UGIB
• Ulcerative/Erosive
• Duodenal and/or Gastric Ulcers
• Esophagitis (infectious vs. pill
induced)
• Gastritis & Duodenitis
• Portal Hypertension
• Esophagogastric Varices
• Ectopic Varices (i.e. small bowel or
rectum)
• Portal Hypertensive Gastropathy
• Vascular Lesions
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Angiodysplasia
GAVE
Blue rubber bleb syndrome
Dieulafoy’s lesion
• Trauma or Iatrogenic
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Mallory-Weiss
Foreign body ingestion
Marginal ulcers
Post-polypectomy
Cameron lesions
Aortoenteric fistula
• Tumors
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Leiomyoma / Lipoma
Polyps
Adenocarcinomas
GI Stromal tumors
Carcinoid
Lymphoma
Metastatic
• Miscellaneous
• Hemobilia
• Hemosuccus pancreaticus
Most Common
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Gastric and/or duodenal ulcers
Esophagogastric varices
Severe or erosive esophagitis
Severe or erosive gastritis/duodenitis
Portal hypertensive gastropathy
Angiodysplasia (also known as vascular
ectasia)
• Mass lesions (polyps/cancers)
• Mallory-Weiss syndrome
• No lesion identified (10 to 15 percent
of patients)
Initial Evaluation of Acute UGIB
H&P: PMH, Meds, Specific symptom assessment
Assess the severity of bleed
• Assess hemodynamic stability
• Mild-moderate: tachycardia
• Blood volume loss >15% : Orthostatic hypotension
• Blood volume loss >40% : Supine hypotension
Labs
• Initial hemoglobin may be normal since the patient is losing whole blood.
• Within typically 24 hours or more, Hb drops as blood is diluted by influx of extravascular fluid
into vascular space & by fluid resuscitation
• BUN: Cr > 1:20 (higher ratio  more likely upper GI bleed)
Nasogastric Lavage
• Data is inconclusive
• Studies do not demonstrate improvement in mortality with use
• Most often used if UGIB is unclear & patient may benefit from shorter time to endoscopy
Risk Stratification
Rockall Score
• Incorporates: Age (0-2), Shock (02), Major comorbidities (0-3),
Diagnosis (0-2), Recent
hemorrhage (0-6)
• Pre & post endoscopy scores
• Attempts to predict mortality, but
has not been shown to clearly
identify patients who require
intervention.
Glasgow Blatchford Score
• More accurate
• Does not need endoscopy
• Incorporates: BUN, Hb, Systolic blood
pressure, Heart rate, melena, syncope,
hepatic disease, cardiac disease
• Score 0-23
• Score of Zero was associated with lowlikelihood of requiring emergent
endoscopy
• Modified Glasgow Blatchford Score
• 0-16, also reliable
Acute Management
• Type & Cross
• 2 large bore peripheral IV (16 gauge or larger)
• Fluids: NS or LR
• Transfusions
• pRBCs: Goal Hb >7 for most patients, Goal Hb >9 for patients with significant
CAD
• NEJM study
• Villanueva et al. 2013, demonstrated that restrictive strategy significantly improved
outcomes
• Platelets if < 50,000
• FFP if INR > 1.5 (* coagulopathy NOT due to cirrhosis )
Villanueva C et al, NEJM 2013
• Single Center, non-blinded, parallel group, randomized control
• N=921
• Restrictive Strategy (n = 461) - transfuse Hb < 7
• Liberal Strategy (n=460) – transfuse Hb < 9
• 2003 – 2009
• Analysis: Intension to treat
• Primary outcome: All-cause mortality at 45 days
• Stratified according to presence/absence of cirrhosis,
randomized to either strategy
• Majority of bleeds were from PUD (49%), Variceal bleed (24%),
Mallory-Weiss tears (7%), Esophagitis (8%) and Malignancy (4%)
• All patients underwent EGD within 6 hours, in addition to
appropriate intervention
• Results:
• Mortality was significantly lower in the restrictive group
rather than liberal group (5% vs 9%, P = 0.02)
• “Risk of bleeding, length of hospital stay, need for rescue
therapy, overall rate of complications and rate of serious
adverse events were all significantly reduced with the
restrictive vs. liberal strategy” (Villanueva et al. NEJM
2013).
Acute Management
• Medications:
• IV Proton Pump Inhibitors: acid suppression
• Octreotide: somatostatin analogs
• Mainly for variceal bleeds
• Dose is IV bolus of 20 – 50 mcg, followed by 25-50 mcg/hr
• Prokinetics: improve gastric visualization by the time of endoscopy
• Erythromycin or Metoclopramide
• Prophylactic Antibiotics for Cirrhotic patients
• Tranexamic acid
Acute Esophageal Variceal Bleeds
• Stabilize patient: Fluids, blood products, octreotide, +/- erythromycin
• Endoscopic Variceal Ligation
• Goal is within 12 hours
• Intubate before endoscopy to avoid aspiration
• Repeat endoscopy for 2-4 sessions: no consensus on time, generally 1-8 week interval
• Adverse effects include post-EVL band-induced ulcer bleeding, which can be as high as 14%.
Notably, studies have shown that PPI therapy post-banding may reduce ulcer burden.
• Endoscopic Sclerotherapy
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Inject sclerosing agent into varix using endoscope
Similar to EVL in controlling initial bleed, however EVL is superior in preventing re-bleeds
• Endoscopic Failure
• Occurs in 10-20% of patients
• If re-bleeding occurs acutely  reasonable to try alternative technique to control bleed
• If uncontrolled bleeding
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Use Balloon tamponade as temporizing measure
TIPSS or Surgical shunting
Adapted from Sanyal A, et al, Semin Liver Dis 1993; 13:4.
TIPSS
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Functions like surgical portocaval shunt, but does not require general anesthesia or major surgery
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At skilled centers, 90-100% of patients achieve hemostasis
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Indications:
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Absolute Contraindications
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Heart failure
Severe tricuspid regurgitation
Severe pulmonary hypertension (mean pulmonary pressure >45 mmHg)
Multiple hepatic cysts
Uncontrolled systemic infection or sepsis
Unrelieved biliary obstruction
Relative Contraindications
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Active hemorrhage despite emergent endoscopic treatment
Recurrent variceal hemorrhage
Hepatoma, especially if central
Obstruction of all hepatic veins
Portal vein thrombosis
Severe coagulopathy
Thrombocytopenia (<20,000/mm3)
Moderate pulmonary hypertension
TIPS is not used for primary prevention
How effective is TIPS
• Data shows that TIPS is significantly better at
preventing variceal re-bleeding rates compared to EST
or EVL.
• Complications
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Technical complications: cardiac arrhythmias, traversal of the liver
capsule, inadvertent creation of TIPS-biliary fistula which can
cause hemobilia, extrahepatic puncture
Portosystemic complications: Encephalopathy, heart failure,
pulmonary edema
Effects of EST vs. TIPS on variceal rebleeding rates
All but the last trial showed significantly lower rebleeding with TIPS
Causes of Bleeding after TIPPS
- Continued hemorrhage
- Persistent gastric varices
- Stent dysfunction
- Hemobilia
Primary Prophylaxis of PSE after TIPS?
- Journal of Hepatology
Pharmacological prophylaxis of hepatic encephalopathy after
transjugular intrahepatic portosystemic shunt; Riggio et al.
Randomized controlled study
Three arms: lactulose 60 g/day vs. rifaximin 1200mg/day) vs.
no therapy
End point: occurrence of hepatic encephalopathy during first
month post-TIPS
Results: One-month incidence was similar in the three groups
(P=0.97).
Prevention of Recurrent Variceal Hemorrhage in Cirrhotic
Patients
AASLD Recommendations - 2007 Guidelines
- Secondary prophylaxis is recommended in patients who survive an
episode of active hemorrhage
- Combination of b-blockers and EVL is the best option
- Max out nonselective BB to tolerable dose
- EVL repeat every 1-2 weeks until obliteration  repeat surveillance
EGD in 1-3 months  repeat every 6-12 months
- Consider TIPS in patients in Child A or B patients who experience
recurrent bleeds despite combination EVL + b-blockers.
- Transplant candidates should be referred to transplant center
ASGE Guidelines
Use of endoscopy in Variceal Hemorrhage
Primary Screening:
No Varices: Repeat every
2-3 years
Compensated cirrhosis
Small Varices: Repeat
every 1-2 years
Screening endoscopy for
patients with cirrhosis
Decompensated cirrhosis
or
Cirrhosis 2/2 ETOH abuse
Yearly Endoscopy
Primary Prophylaxis with EVL:
- Large esophageal varices and cannot tolerate
beta blockers
- B-blocker or EVL if large varices and ChildsPugh C
- Perform EVL at 1-8 week intervals until
variceal eradication is complete
- Surveillance EGD 1-3 months after
eradication and repeat endoscopy every 1-2
years to monitor for recurrence
Secondary Prophylaxis
- Combination of non-selective beta-blockers and
EVL is the best option
References
Bajaj, JS. Methods to achieve hemostasis in patients with acute variceal hemorrhage. In: UpToDate, Runyon, B (Ed), UpToDate, Accessed on January 24, 2017.
Bajaj, JS. Role of transjugular intrahepatic portosystemic shunts in the treatment of variceal bleeding. In: UpToDate, Chopra, S (Ed), UpToDate, Accessed on January 24, 2017
Riggio O, Masini A, Efrati C, et al. Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study. J Hepatol 2005; 42:674
"Rockall Score for Upper GI Bleeding. ." MDCalc. N.p., 2016. Web. 24 Jan. 2016.
Rockey, DC. Causes of upper gastrointestinal bleeding in adults. In: UpToDate, Feldman, M (Ed), UpToDate, Accessed on January 23, 2017.
Saltzman, JR. Approach to acute upper gastrointestinal bleeding in adults. In: UptoDate, Feldman, M (Ed), UpToDate, Accessed on January 23, 2017.
Sanyal, AJ. General principles of the management of variceal hemorrhage. In: UpToDate, Runyon, B (Ed), UpToDate, Accessed on January 23, 2017.
Sanyal, AJ. Transjugular intrahepatic portosystemic shunts: Complications. In: UpToDate, Chopra, S (Ed), UpToDate, Accessed on January 23, 3017.
Sanyal, AJ. Transjugular intrahepatic portosystemic shunts: Indications and contraindications, Runyon, B (Ed), UpToDate, Accessed on January 23, 2017.
Villanueva , C. et al. "Transfusion strategies for acute upper gastrointestinal bleeding." New England Journal of Medicine 368.1 (2013): 11-21. Web.
"The role of endoscopy in the management of variceal hemorrhage." Gastrointestinal Endoscopy 80.2 (2014): 221-27. ASGE . American Society Of Gastrointestinal Endoscopy . Web. 22 Jan. 2017